Registration Form

( 25.00 returning students/35.00 Family,  30.00 new students/40.00 Family) - form can be emailed to - pls state payment in mail - or mail payment and form to SMDA, P.O. Box 314 Valley Lee MD, 20692.  Tuition is due first day of class. Non -Refundable registration fee holds your space in the class. 

Please fill out one for each child 
Student Name:­­­­­­­­­­­­­­­­­­­­­­­­­­ _______________________________ Age:________ DOB:___________

If under 18 – Parent/Guardian Name: __________________________________________
Relationship to Student: ______________________

Mailing Address: ___________________________________________________________

Where Did You Hear About Us? ___________________________________

Home Phone: ________________ Work Phone: __________________ Cell:___________________
Please print legibly, as this is our main form of communication

Email: ________________________________ Alternate email or phone _______________________

Classes registering for: example: 
        Class:  Cheer   (5 – 7 yr)                    Day/time     Monday 6:00 – 6:45
        Class   _____________________      Day/time ________________________
        Class   ______________________    Day/time ________________________

        Class   ______________________    Day/time ________________________
        Class   ______________________    Day/time ________________________
Tuition is due on the first day of class of each month. A 10.00 late fee is imposed if tuition is more than 7 days late.  After the 14th of the month the late fee is automatically added on – see student handbook.      
WAIVER AND RELEASE OF CLAIMS.  Parent/Guardian and dancer recognize there is a risk of injury in any type of dance/sport program.  Parent/Guardian acknowledges that the student is participating upon his/her express agreement that injury may occur and agrees to release St. Mary’s Dance Academy Inc., its employees, directors, volunteers from any and all liability relating to any accident.  St. Mary’s Dance Academy Inc. does not carry medical insurance for students.  All students are required to be covered by their own family health insurance in the event of sickness or an injury.  As the parent/guardian/student, I accept the financial responsibility for treatment of the student should the need arise during any and all St. Mary’s Dance Academy Inc. programs.  I agree not to hold St. Mary’s Dance Academy Inc., and any assigned representative financially responsible for the care or treatment that may be needed.  I hereby waive and absolve St. Mary’s Dance Academy, Inc. of any liability and responsibility for injuries, damages, or losses incurred during participation of any and all programs, activities, events associated with St. Mary’s Dance Academy, Inc. by myself and/or child. 
Date______________________      Printed Name (of person signing): ____________________________

Signature ____________________________________( Signature of Parent/Guardian – if under 18 years.  Signature of student if 18 years or older.